Everwind Hospice

“Based on record review, staff interview, and Performance Improvement Plan (PIP) review, the agency failed to ensure volunteers were used in administrative and/or direct patient care roles (refer to L644) and failed to demonstrate ongoing efforts to recruit volunteers (refer to L645). In addition, the facility failed to document the cost savings achieved through the use of volunteers (refer to L646). Further, the facility failed to ensure volunteers provided administrative and/or direct patient care hours in an amount that equaled, at a minimum, 5 percent of the total patient care hours of all paid employees and contract staff (refer to L647). This system failure resulted in the inability of the facility to meet the Condition of Participation for Volunteers.”

“Based on record review, staff interview, policy review, and Performance Improvement Plan (PIP) review the agency failed to ensure volunteer services were provided. The findings were: 1. Review of the active staff list hand delivered on 3/3/26 at 2:30 PM showed no volunteers were included. 2. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time. 3. Review of the policy “Volunteer Services” hand delivered on 3/5/26 at 10:15 AM by the ED showed “...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services...”4. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement showed “Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement...” The Identified Discrepancies showed “...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program.””

“Based on staff interview, policy review, and review of a Performance Improvement Plan (PIP), the agency failed to ensure an ongoing effort for recruitment and retention of volunteers. The findings were: 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. She revealed the agency had not had any volunteers prior to that time. She also revealed the agency had gone to a high school, and a community center to try and recruit. 2. Review of the policy “Volunteer Services” hand delivered on 3/5/26 at 10:15 AM by the ED showed “...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services...” “...6.The Coordinator is responsible for planning, organizing, documenting and direction the comprehensive volunteer services program. Coordination duties include, but are not limited to: On-going recruiting and training of sufficient numbers of volunteers to meet the needs of patients/families regardless of race, gender, ...” 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show “Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement...” The Identified Discrepancies showed “...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program.””

“Based on staff interview, policy review, and review of a Performance Improvement Plan (PIP), the agency failed to document cost savings through the use of volunteers. The findings were: 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time. Therefore, the agency could not document cost savings. 2. Review of the policy “Volunteer Services” hand delivered on 3/5/26 at 10:15 AM by the ED showed “...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services...” 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show “Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement...” The Identified Discrepancies showed “...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program.””

“Based on staff interview, policy review, and Performance Improvement Plan (PIP) review, the agency failed to ensure volunteer services were provided to equal at least 5% of the total patient care hours. The findings were: 1. Interview with the Executive Director (ED) on 3/5/26 at 10 AM revealed the agency just hired their first volunteer. The person had committed to 1 to 2 hours weekly. She revealed the agency had not had any volunteers prior to that time. Therefore, the volunteer services did not meet the 5% total patient care hours. 2. Review of the policy “Volunteer Services” hand delivered on 3/5/26 at 10:15 AM by the ED showed “...Hospice uses volunteers in administrative or direct patient care roles under the supervision of Volunteer Coordinator. Volunteers are considered Hospice employees to facilitate compliance with core services...” 3. Review of the PIP showed a start date of 2/6/26. The problem statement/opportunity for improvement show “Through ongoing QAPI review, internal audit, or census and utilization monitoring, the agency identified a deficiency in meeting the CMS hospice volunteer requirement...” The Identified Discrepancies showed “...Volunteer hours below the required 5% threshold. Inadequate recruitment and retention of hospice volunteers. Volunteer services not integrated into patient care plans. Lack of volunteer program.””